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-9� C%f9z <br /> Burnett County Office of Zoning Administrator C/) - —I z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 o <br /> g <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < H 0 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use - <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> aJ"�' e ..... ........................ <br /> N. <br /> O <br /> ( <br /> ...../ a /' &,07W CONTRACTOR or SURV. YOR.o..r..A. GE.N.T......... <br /> .........................O n <br /> s-� m <br /> ADDRESS tJ <br /> ADDRESS .�..........��.......... ............ � •� <br /> ADD <br /> ....... .ESS•...................y ..... .•...... ....... <br /> .. <br /> . <br /> ........ A..DDRESS.. <br /> ... .. .............................................................................. <br /> .... .. <br /> PHONE <br /> PHONE <br /> PLUMBER : :� <br /> WELL DRILLER <br /> ADDRESS ... ................................................................ <br /> ADD...R.ESS...... ............ <br /> CD <br /> PHONEP ONE o....................................................................................... r �' <br /> H �` <br /> DESCRIPTION z y <br /> 4. Sanitary Facilities: o o t <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> o 0 <br /> New Building T 1 o <br /> Type of Construction: No. Bedrooms .......... m <br /> Addition .................................................... Septic Tank Size Gals. <br /> CD <br /> Sanitary Size .............. ft. x .............. ft. .......... < i <br /> Filling ,X.... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type <br /> ......... Area ........................................... p .................................... <br /> Grading r <br /> .......... <br /> Sloe .........................................: o <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate .................................. <br /> Privy home,garage, motel, etc.) Dry Well <br /> .......... <br /> Well Seepage Trench <br /> .......... . . <br /> Subdivision Privy J <br /> ------------------------------- Seepage Bed ..... <br /> _ocation of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include road .O C <br /> ;etback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a :� <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> ;TRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. y' <br /> -------------------------------------- <br /> i. Lo Size: -------------------------------- o <br /> Fig. A. 6. Location: <br /> to ft. x .j Od... ft. — ........ sq. ft. <br /> Cn <br /> 3 p c <br /> N 0' <br /> o = <br /> _ <br /> w ' <br /> P <br /> O& <br /> CD <br /> ofu <br /> Z <br /> _ <br /> CD <br /> z n ' <br /> � z(D <br /> CD. ry °-Q- <br /> m <br /> gnature of or Agent � Date.... o C <br /> y" <br /> :marks ......... tl'i................. . ..... ..hA <br /> X <br /> .................... 0 <br /> ........................................................................ { <br /> ................................ :o : . : : . <br /> spection Date ....................................... �,�... ............... ................................. ��: o 0 0 0.Ln m <br /> ;�'� Zoning Ad istrator o 0 0 0 o y <br /> TE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> ore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> n rs round to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />